Provider Demographics
NPI:1154624658
Name:FERNANDEZ, KAITLIN MARY CORYAT (MA, BCBA, LBA)
Entity type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:MARY CORYAT
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MARY
Other - Last Name:CORYAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA, LBA
Mailing Address - Street 1:85 DUNKIRK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1707
Mailing Address - Country:US
Mailing Address - Phone:607-437-2815
Mailing Address - Fax:
Practice Address - Street 1:85 DUNKIRK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-1707
Practice Address - Country:US
Practice Address - Phone:607-437-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-10-7532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1-10-7532OtherBEHAVIOR ANALYST CERTIFICATION BOARD